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ops o bo X1760 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT �i www.sjgov.org/ehd I PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS E 1 I.CITY/ZIP 1 eh 1693b <br /> m <br /> (� �J1t� D <br /> CROSS STREET SC-A' tt� 691Mh S4 O�APN � `2)'`i O`� ` PARCEL SIZE ` i LAND USE APPLICATION# p <br /> OWNER NAME �I!*M :rr 55 C t/•! ) I I IC;Wi .� �{! C'kid jrc' ,"I " � PHONE / / y <br /> OWNER ADDRESS n� �''x C�1 CITY/STATE2IP t-!%"'r�(in�11 ! `/,5 �{3h <br /> CONTRACTOR 1`K.�C�� O 604-sr, T`e'noteJ, PHONE' P A, -�61-3% <br /> CONTRACTOR ADDRESS `O� T'Am A 1Vh'y�Qa CITY/STATE/ZIP ~�C <br /> SUBCONTRACTOR/CONSULTANT S1 t f, AS <br /> '"160VC PHONEWF_ K 0OYE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ��""'� y� IC,IITAY/S�TTAAT��Ev21P �' A 1i lis ��OJ <br /> LICENSE C-57 I C-61 D-09 Other NUMBER ` 60k I EXPIRATION DATE!�_Vy 202� <br /> BILLING PARTY: OWNER ACONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i_I Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well i Replacement Well [-] Well Alteration/Modification i Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ,1 Geotechnical 3 a of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement i i Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth NO ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _i Steel i Plastic _i Stainless Steel Other <br /> Grout Seal Depth H0 ft NNeat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> i Bentonite(20%solids) - Other <br /> Grout Placement Method I'i Pumped 11 Free Fall t Other TV1'M'4 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller IPump Contractor Other <br /> Concrete Pedestal i 1Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP 1 Submersible Turbine - Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> �INSPECTIONS -PLEASE CALL(209Q) 953-7697 <br /> SIGNED TITLE C ^A Q)e0((* bT1DATE <br /> LJ <br /> A <br /> i OL NTY <br /> N IR N E Trp�q TV ENT <br /> i L <br /> �-� DEPARTMENT USE ONLY <br /> Application Accepted By /G- ��/_ Date Sh Area L + Employee ID# <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By Z Date WAIVER Received <br /> Soil Boring Inspection By ��5+✓ ' Date 2:5" ?f% Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Cheek#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> D <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />